Methods for simultaneous cardiac substrate mapping using spatial correlation maps between neighboring unipolar electrograms

ABSTRACT

A base cardiac electrogram signal at a base electrode is recorded for a predetermined amount of time. A plurality of cardiac electrogram signals at a plurality of electrodes other than the base electrode are recorded for the predetermined amount of time. The base cardiac electrogram signal is compared with each of the plurality of cardiac electrogram signals. The similarities between the base cardiac electrogram signal and each of the plurality of cardiac electrogram signals is determined. A specific area of cardiac tissue where the base electrode is positioned is mapped based at least in part on the determined similarities.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a divisional of patent application Ser. No.13/773,162 (now U.S. Pat. No. 9,031,642), filed Feb. 21, 2013, entitledMETHODS FOR SIMULTANEOUS CARDIAC SUBSTRATE MAPPING USING SPATIALCORRELATION MAPS BETWEEN NEIGHBORING UNIPOLAR ELECTROGRAMS, the entiretyof which is incorporated herein by reference.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

n/a

FIELD OF THE INVENTION

The present invention relates to a method and system for mapping cardiacsubstrate.

BACKGROUND OF THE INVENTION

A cardiac arrhythmia is a condition in which the heart's normal rhythmis disrupted. There are many types of cardiac arrhythmias, includingsupraventricular arrhythmias that begin above the ventricles (such aspremature atrial contractions (PACs), atrial flutter, accessory pathwaytachycardias, atrial fibrillation, and Atrioventricular nodal reentranttachycardia (AVNRT)), ventricular arrhythmias that begin in the lowerchambers of the heart (such as premature ventricular contractions(PVCs), ventricular tachycardia (VT), ventricular fibrillation, and longQT syndrome), and bradyarrhythmias that involve slow heart rhythms andmay arise from disease in the heart's conduction system. Further,cardiac arrhythmias may be classified as reentrant or non-reentrantarrhythmias. In reentrant arrhythmias, the propagating wave ofbioelectricity that normally spreads systematically throughout the fourchambers of the heart instead circulates along a myocardial pathway andaround an obstacle (reentry point) or circulates freely in the tissue asa scroll wave or spiral (referred to herein as “rotors”). Innon-reentrant arrhythmias, propagation of the normal bioelectricity wavemay be blocked or initiated at abnormal (ectopic) locations.

Certain types of cardiac arrhythmias, including ventricular tachycardiaand atrial fibrillation, may be treated by ablation (for example,radiofrequency (RF) ablation, cryoablation, ultrasound ablation, laserablation, and the like), either endocardially or epicardially. However,a physician must first locate the point of reentry, ectopic focus, orregions of abnormal conduction to effectively treat the arrhythmia.Unfortunately, locating the best site for ablation has proven to be verydifficult, even for the most skilled physicians.

Cardiac electrical mapping (mapping the electrical activity of the heartthat is associated with depolarization and/or repolarization of themyocardial tissues) is frequently used to locate an optimal site forablation, for instance, a reentry point, ectopic focus, or a site ofabnormal myocardium. However, the source of an arrhythmia may bedifficult to determine based upon the sensed electrogram morphology. Inaddition to signals emanating from the local myocardium, the electrogrammorphology may include fractionation due to poor electrode contact,electrode design, or complex electrical activity in the vicinity of theelectrodes. The signals may also include “far-field” content fromdistant tissues (such as detection of ventricular activity on atrialelectrodes) or the signal may be attenuated due to disease, ischemia, ortissue necrosis. Further, ablation of one or more identified sites mayalso be problematic.

To date, such ablations require either substantial trial and error (forexample, ablation of all sources of complex fractionated electrograms)or the use of separate mapping and ablation devices (complex mappingsystems utilizing multielectrode arrays or baskets may be used toidentify an ablation site, but cannot also be used to ablate thetissue). The long term success of treating arrhythmias often depends onthe determination of the exact tissue or trigger in the heart causingthe arrhythmia so that the malfunctioning tissue can be ablated and thenormal rhythm of the heart restored. Ablation of arrhythmias, likeatrial fibrillation, whether paroxysmal or chronic, typically involvesthe simultaneous mapping of a region of cardiac tissue with amulti-electrode catheter in order to identify and ablate tissue sourcesor drivers of arrhythmias.

Mapping often includes analyzing a displayed electrogram signal in orderto identify arrhythmic sites and possible ablation targets. However, incomplex electrograms, as in those in patients with atrial fibrillation,the electro gram signals may include several deflections making anaccurate real-time determination of target tissue regions cumbersome andambiguous.

SUMMARY OF THE INVENTION

The present invention advantageously provides a method and system formapping cardiac tissue. In an exemplary embodiment, the method includesrecording a base cardiac electrogram signal at a base electrode for apredetermined amount of time. A plurality of cardiac electrogram signalsat a plurality of electrodes other than the base electrode are recordedsimultaneously for the predetermined amount of time. The base cardiacelectrogram signal is compared with each of the plurality of cardiacelectrogram signals. The similarities between the base cardiacelectrogram signal and each of the plurality of cardiac electrogramsignals is determined. A specific area of cardiac tissue where the baseelectrode is positioned is mapped based at least in part on thedetermined similarities.

In another embodiment, a medical system includes a medical deviceincluding a base electrode and a plurality of electrodes. A control unitin communication with the base electrode and the plurality of electrodesis included, the control unit being operable to: record a base cardiacelectrogram signal at the base electrode for a predetermined amount oftime; record a plurality of cardiac electrogram signals at the pluralityof electrodes other than the base electrode for the predetermined amountof time; compare the base cardiac electrogram signal with each of theplurality of cardiac electrogram signals; determine similarities betweenthe base cardiac electrogram signal and each of the plurality of cardiacelectrogram signals; and map a specific area of cardiac tissue where thebase electrode is positioned based at least in part on the determinedsimilarities.

In yet another embodiment, a method for treating arrhythmogenic cardiactissue is provided. A base cardiac electrogram signal at a baseelectrode is recorded for a predetermined amount of time. A plurality ofcardiac electrogram signals at a plurality of electrodes other than thebase electrode are recorded for the predetermined amount of time. Thebase cardiac electrogram signal is compared with each of the pluralityof cardiac electrogram signals. An average correlation coefficientassociated with the base cardiac electrogram signal and each of theplurality of cardiac electrogram signals is determined. A specific areaof cardiac tissue where the base electrode is positioned is mapped basedat least in part on the determined similarities. The average correlationcoefficient is analyzed to determine whether the average correlationcoefficient has a low value. The specific area of cardiac tissue isidentified as arrhythmogenic cardiac tissue when the average correlationcoefficient has a low value. A medical device including an ablationelement is provided. A closed boundary between the arrhythmogeniccardiac tissue and surrounding cardiac tissue is identified based atleast in part on the average correlation coefficient. The medical deviceis placed in contact with the arrhythmogenic cardiac tissue. Theablation element is activated and substantially all of thearrhythmogenic cardiac tissue within the boundary is ablated.

BRIEF DESCRIPTION OF THE DRAWINGS

A more complete understanding of the present invention, and theattendant advantages and features thereof, will be more readilyunderstood by reference to the following detailed description whenconsidered in conjunction with the accompanying drawings wherein:

FIG. 1 is an illustration of an example of a medical system constructedin accordance with the principles of the present invention;

FIG. 2 is an illustration of an example of a medical device assemblyconstructed in accordance with the principles of the present invention;

FIG. 3 is another illustration of an example of a medical deviceassembly constructed in accordance with the principles of the presentinvention;

FIG. 4 is still another illustration of an example of a medical deviceassembly constructed in accordance with the principles of the presentinvention;

FIG. 5 is yet another illustration of an example of a medical deviceassembly constructed in accordance with the principles of the presentinvention;

FIG. 6 is a block diagram of an electrode mapping grid in accordancewith the principles of the present invention;

FIG. 7 is a graph of an exemplary correlation map constructed inaccordance with the principles of the present invention;

FIG. 8 is a graph of another exemplary cardiac correlation mapconstructed in accordance with the principles of the present invention;

FIG. 9 is an illustration of three different electrogram signals inaccordance with the principles of the present invention;

FIG. 10 is a graph of still another exemplary correlation map createdusing both positive and negative correlation coefficients constructed inaccordance with the principles of the present invention; and

FIG. 11 is a flow chart illustrating an exemplary method of cardiacsubstrate mapping using spatial correlation maps between neighboringunipolar electrograms.

DETAILED DESCRIPTION OF THE INVENTION

Substrate mapping, sequential or simultaneous, may be used to identifyarrhythmia circuits that are often the targets of ablation. Sequentialmapping may involve using a roving catheter probe to record electricalactivity, such as potentials, voltages and electrograms, at a time andpoint within the myocardium, and then moving the catheter to anotherpoint to record electrical activity at a different subsequent time.Simultaneous substrate mapping may involve using a multi-electrodebasket catheter to record electrical activity simultaneously overmultiple points within a region of mapping. The processing of therecorded electrical information helps identify the arrhythmia circuit.

Conventional mapping involves extracting cardiac activation times bypicking up points of deflection or steepest negative slope, anddisplaying the times over a surface (isochronal map). The patternsduring an arrhythmia are observed. For example, an observed pattern mayinclude a rotor around which electrical activation rotates during atrialfibrillation. However, extraction of activation times becomes difficultwhen the recorded electrogram signals are complex and consist ofmultiple deflections. Processing of such electrogram signals to identifyvalid information may also be a time-consuming process, precludingreal-time applications of such method during mapping and ablationprocedures.

Successful ablation of arrhythmias like AF relies on methods which canefficiently and accurately identify appropriate ablation targets. Forexample, rotors associated with AF have been shown to be successfulablation targets in trials. However, methods for identification of suchrotors require a significant amount of electrogram signalpre-processing, which may prevent the application of such methodsuniversally and/or in real-time. The present disclosure describesmethods of creating spatial maps of correlation of electrograms betweenspatially adjacent electrodes that may be simpler to implement thanprevious methods. The method disclosed may be more universallyapplicable than the previous methods for identifying cardiac substratethat can be the target of ablation.

As such, the present invention advantageously provides a system andmethods of use thereof for simultaneous cardiac substrate mapping usingspatial correlation maps between neighboring unipolar electrograms. Inan exemplary embodiment, a two-dimensional (“2D”) or three-dimensional(“3D”) spatial map of correlation coefficients is created. Thecorrelation coefficient at a given point on the correlation map may becalculated by averaging the simple Pearson correlation coefficientsbetween a unipolar electrogram signal recorded at an electrodepositioned at that given point, and simultaneously recorded unipolarelectrogram signals at spatially adjacent electrodes. The 2D or 3Dcorrelation map created may be displayed on a display system, whereinthe image includes a visual representation of the average of thecorrelation coefficients calculated.

Regions in the correlation map may be automatically delineated where thecorrelation coefficient values are less than a pre-specified threshold.The border between regions of high correlation and regions of lowcorrelations may be identified as the defining boundary of thedriver/rotor of the arrhythmia circuit. Areas of low correlation withinsuch boundaries may be selected as possible ablation targets fortermination of arrhythmias. Such correlation maps may be created overmultiple epochs or cycles to identify the movement of the border(rotor). The trajectory of the border between areas of low and highcorrelation over multiple cycles may also be delineated on a displaysystem to indicate the possible areas of RF/cryo-ablation. In some casessignal morphology may vary from one cycle to another. For example therotor may not be stable from one cycle to other, but may exhibit somespatial movement. In those cases, the morphology of egm at the sitein/near the rotor may change from one cycle to another.

A method of creating spatial maps of correlated electrogram signals fromspatially adjacent electrodes belonging to a multi-electrode system toidentify arrhythmia circuits and possible ablation targets is provided.An exemplary application may involve identifying rotors associated withatrial fibrillation from electrical recordings obtained from amulti-electrode balloon catheter or a constellation catheter.

Referring now to the drawing figures in which like referencedesignations refer to like elements, an embodiment of a medical systemconstructed in accordance with principles of the present invention isshown in FIG. 1 and generally designated as “10.” The system 10generally includes a medical device 12 that may be coupled to a controlunit 14 or operating console. The medical device 12 may generallyinclude one or more diagnostic or treatment regions for energetic,therapeutic and/or investigatory interaction between the medical device12 and a treatment site or region. The diagnostic or treatment region(s)may deliver, for example, cryogenic therapy, radiofrequency energy, orother energetic transfer with a tissue area in proximity to thetreatment region(s), including cardiac tissue.

The medical device 12 may include an elongate body 16 passable through apatient's vasculature and/or proximate to a tissue region for diagnosisor treatment, such as a catheter, sheath, or intravascular introducer.The elongate body 16 may define a proximal portion 18 and a distalportion 20, and may further include one or more lumens disposed withinthe elongate body 16 thereby providing mechanical, electrical, and/orfluid communication between the proximal portion of the elongate body 16and the distal portion of the elongate body 16, as discussed in moredetail below.

The medical device 12 may include a shaft 22 at least partially disposedwithin a portion of the elongate body 16. The shaft 22 may extend orotherwise protrude from a distal end of the elongate body 16, and may bemovable with respect to the elongate body 16 in longitudinal androtational directions. That is, the shaft 22 may be slidably and/orrotatably moveable with respect to the elongate body 16. The shaft 22may further define a lumen 24 therein for the introduction and passageof a guide wire. The shaft 22 may include or otherwise be coupled to adistal tip 26 that defines an opening and passage therethrough for theguide wire.

The medical device 12 may further include a fluid delivery conduit 28traversing at least a portion of the elongate body and towards thedistal portion. The delivery conduit 28 may be coupled to or otherwiseextend from the distal portion of the elongate body 16, and may furtherbe coupled to the shaft 22 and/or distal tip of the medical device 12.The fluid delivery conduit 28 may define a lumen therein for the passageor delivery of a fluid from the proximal portion of the elongate body 16and/or the control unit 14 to the distal portion and/or treatment regionof the medical device 12. The fluid delivery conduit 28 may furtherinclude one or more apertures or openings therein, to provide for thedispersion or directed ejection of fluid from the lumen to anenvironment exterior to the fluid delivery conduit 28.

The medical device 12 may further include one or more expandableelements 30 at the distal portion of the elongate body 16. Theexpandable element 30 may be coupled to a portion of the elongate body16 and also coupled to a portion of the shaft 22 and/or distal tip 26 tocontain a portion of the fluid delivery conduit 28 therein. Theexpandable element 30 defines an interior chamber or region thatcontains coolant or fluid dispersed from the fluid delivery conduit 28,and may be in fluid communication with an exhaust lumen 32 defined by orincluded in the elongate body 16 for the removal of dispersed coolantfrom the interior of the expandable element 30. The expandable element30 may further include one or more material layers providing forpuncture resistance, radiopacity, or the like.

The medical device 12 may further include one or moreelectrically-conductive segments or electrodes 34 positioned on or aboutthe elongate body for conveying an electrical signal, current, orvoltage to a designated tissue region and/or for measuring, recording,or otherwise assessing one or more electrical properties orcharacteristics of surrounding tissue. The electrodes 34 may beconfigured in a myriad of different geometric configurations orcontrollably deployable shapes, and may also vary in number to suit aparticular application, targeted tissue structure or physiologicalfeature. For example, as shown in FIG. 1, the electrodes 34 may includea first pair proximate to the expandable element and a second electrodepair distal to the expandable element. Alternative electrodeconfigurations of the medical device 12 are illustrated in FIGS. 2-5.FIG. 2 includes an electrode array 36 configurable into a looped orsubstantially circular configuration. The electrode array 36 in FIG. 3includes a plurality of arms 38, with the electrodes 34 positioned in aproximal-facing direction or orientation on the arms 38. FIG. 4 alsoincludes a plurality of extendable or deployable arms 38 having aplurality of electrodes 34 in a square-like or “X”-shaped configuration.Turning to FIG. 5, a plurality of electrodes 34 are shown in asubstantially linear array 36 extending along a portion of the elongatebody 16 of the medical device 12. In each of these embodiments shown inFIGS. 2-5, the electrodes 34 may be positioned on the medical device 12substantially equidistant from an adjacent electrode 34 in the array ormay be variable distances from each adjacent electrode 34.

Each electrode 34 may be electrically coupled to an output portion of aradiofrequency signal generator, and each electrode 34 may also includea sensor, such as a thermocouple, an electrical conductivity sensor, aspectrometer, a pressure sensor, a fluid flow sensor, a pH sensor,and/or a thermal sensor (not shown) coupled to or in communication withthe electrodes. The sensors may also be in communication with a feedbackportion of the control unit 14 to trigger or actuate changes inoperation when predetermined sequences, properties, or measurements areattained or exceeded.

Referring again to FIG. 1, the medical device 12 may include a handle 40coupled to the proximal portion of the elongate body 16. The handle 40can include circuitry for identification and/or use in controlling ofthe medical device 12 or another component of the system. Additionally,the handle 40 may be provided with a fitting 42 for receiving a guidewire that may be passed into the guide wire lumen 24. The handle 40 mayalso include connectors 44 that are mateable to the control unit 14 toestablish communication between the medical device 12 and one or morecomponents or portions of the control unit 14.

The handle 40 may also include one or more actuation or control featuresthat allow a user to control, deflect, steer, or otherwise manipulate adistal portion of the medical device 12 from the proximal portion of themedical device 12. For example, the handle 40 may include one or morecomponents such as a lever or knob 46 for manipulating the elongate body16 and/or additional components of the medical device 12. For example, apull wire 48 with a proximal end and a distal end may have its distalend anchored to the elongate body 16 at or near the distal portion 20.The proximal end of the pull wire 48 may be anchored to an element suchas a cam in communication with and responsive to the lever 46. Themedical device 12 may include an actuator element 50 that is movablycoupled to the proximal portion of the elongate body 16 and/or thehandle 40 for the manipulation and movement of a portion of the medicaldevice 12, such as the shaft 22, and/or one or more portions of theelectrode assemblies described above, for example.

The system 10 may include one or more treatment sources coupled to themedical device for use in an operative procedure, such as tissueablation, for example. The control unit 14 may include a fluid supply 52including a coolant, cryogenic refrigerant, or the like, an exhaust orscavenging system (not shown) for recovering or venting expended fluidfor re-use or disposal, as well as various control mechanisms. Inaddition to providing an exhaust function for the fluid or coolantsupply 52, the control unit 14 may also include pumps, valves,controllers or the like to recover and/or re-circulate fluid deliveredto the handle 40, the elongate body 16, and/or the fluid pathways of themedical device 12. A vacuum pump 54 in the control unit 14 may create alow-pressure environment in one or more conduits within the medicaldevice 12 so that fluid is drawn into the conduit(s)/lumen(s) of theelongate body 16, away from the distal portion 20 and towards theproximal portion 18 of the elongate body 16.

The control 14 unit may include a radiofrequency generator or powersource 56 as a treatment or diagnostic mechanism in communication withthe electrodes 34 of the medical device 12. The radiofrequency generator56 may have a plurality of output channels, with each channel coupled toan individual electrode 34. The radiofrequency generator 56 may beoperable in one or more modes of operation, including for example: (i)bipolar energy delivery between at least two electrodes on the medicaldevice within a patient's body, (ii) monopolar or unipolar energydelivery to one or more of the electrodes 34 on the medical device 12within a patient's body and through a patient return or ground electrode(not shown) spaced apart from the electrodes 34 of the medical device14, such as on a patient's skin for example, and (iii) a combination ofthe monopolar and bipolar modes.

The system 10 may further include one or more sensors to monitor theoperating parameters throughout the system, including for example,pressure, temperature, flow rates, volume, power delivery, impedance, orthe like in the control unit 14 and/or the medical device 12, inaddition to monitoring, recording or otherwise conveying measurements orconditions within the medical device 12 or the ambient environment atthe distal portion of the medical device 12. The sensor(s) may be incommunication with the control unit 14 for initiating or triggering oneor more alerts or therapeutic delivery modifications during operation ofthe medical device 12. One or more valves, controllers, or the like maybe in communication with the sensor(s) to provide for the controlleddispersion or circulation of fluid through the lumens/fluid paths of themedical device 12. Such valves, controllers, or the like may be locatedin a portion of the medical device 12 and/or in the control unit 14.

The control unit 14 may include one or more controllers, processors,and/or software modules containing instructions or algorithms to providefor the automated operation and performance of the features, sequences,calculations, or procedures described herein. For example, the controlunit 14 may include a signal processing unit 58 to measure one or moreelectrical characteristics between the electrodes 34 of the medicaldevice 12. An excitation current may be applied between one or more ofthe electrodes 34 on the medical device 12 and/or a patient returnelectrode, and the resulting voltage, impedance, or other electricalproperties of the target tissue region may be measured, for example, inan electrogram, as described in more detail below. Unipolar electrograms(“egms”) may be recorded with the mapping electrode 34 as the positiveelectrode, and another electrode 34 on the body surface or remote fromthe field or cardiac excitation as the negative electrode. The controlunit may further include a display 60 to display the various recordedsignals and measurement, for example, an electrogram.

FIG. 6 is a block diagram of an exemplary electrode mapping grid 62,including base electrode e 34 a, electrode e1 34 b, electrode e2 34 c,electrode e3 34 d, electrode e4 34 e, electrode e5 34 f, electrode e6 34g, electrode e7 34 h and electrode e8 34 i. Additionally, electrodemapping grid 62 includes electrodes 34 j, 34 k, 34 l, 34 m, 34 n, 34 o,34 p, 34 q, 34 r, 34 s, 34 t, 34 u, 34 v, 34 w, 34 x and 34 y.Electrodes 34 within a certain predefined physical distance d of baseelectrode e 34 a may be referred to as neighbor/neighboring electrodes34. The distance d can be any value between one millimeter and twentymillimeters.

The exact distance may depend on the particular design andinter-electrode spacing of the medical device 12, e.g., the mappingcatheter. In the exemplary electrode mapping grid 62, the distancebetween each electrode 34 is two millimeters. As such, for a pre-definedvalue of d of two millimeters, the electrodes 34 that are neighbors ofbase electrode e 34 a include electrodes e1 34 b, electrode e2 34 c,electrode e3 34 d, electrode e4 34 e, electrode e5 34 f, electrode e6 34g, electrode e7 34 h and electrode e8 34 i.

In an exemplary embodiment, a base cardiac electrogram signal isrecorded at the base electrode e 34 a for a predetermined amount oftime, which may be the length of an arrhythmia cycle. Electrogramsignals at electrode e1 34 b, electrode e2 34 c, electrode e3 34 d,electrode e4 34 e, electrode e5 34 f, electrode e6 34 g, electrode e7 34h and electrode e8 34 i are recorded simultaneously to the recording ofthe base cardiac electrogram signal for the same predetermined amount oftime.

The electrogram signals may be recorded for several milliseconds. Forexample, the electrogram signals may be recorded for 100 ms to 350 ms,i.e., the length of time the electrogram signal is recorded may equalthe length of time of an arrhythmia cycle, which is usually 100 ms to350 ms. The recording may be performed over multiple arrhythmia cycles,the correlation map may be created for each cycle, and spatial displayof the maps over multiple cycles may be presented to track the movementof the boundary between areas of low and high correlation.

The base cardiac electrogram signal and the plurality of cardiacelectrogram signals may be recorded simultaneously. Recording the basecardiac electrogram signal at the same time as the plurality ofelectrogram signals from the neighboring electrodes 34 may ensure thatall of the electrogram signals correspond to a particular arrhythmiacycle. Correlation maps may be constructed over each cycle and analysisof correlation-maps may be performed over multiple cycles to track thetrajectory of the areas of low and high correlation over multiplecycles.

In order to map the location where electrode e 34 a is positioned, theelectrogram signal recorded at base electrode e 34 a is compared to eachof the other electrogram signals of the other electrodes 34, i.e., toeach electrogram signal from electrode e1 34 b, electrode e2 34 c,electrode e3 34 d, electrode e4 34 e, electrode e5 34 f, electrode e6 34g, electrode e7 34 h and electrode e8 34 i.

In this exemplary embodiment, only the electrogram signals fromneighboring electrodes 34 that are neighbors to electrode e 34 a (e.g.,electrode e1 34 b, electrode e2 34 c, electrode e3 34 d, electrode e4 34e, electrode e5 34 f, electrode e6 34 g, electrode e7 34 h and electrodee8 34 i) are compared to the base cardiac electrogram signal from baseelectrode e 34 a. However, the invention is not limited to such, as anynumber of electrogram signals from any number of electrodes 34 may becompared to any electrogram signal from any electrode 34.

The similarities between the electrogram signals are determined, i.e.,the similarities between the base cardiac electrogram signal and each ofthe plurality of cardiac electrogram signals from electrode e1 34 b,electrode e2 34 c, electrode e3 34 d, electrode e4 34 e, electrode e5 34f, electrode e6 34 g, electrode e7 34 h and electrode e8 34 i aredetermined. For example, the similarities between (i) the base cardiacelectrogram signal and the cardiac electrogram signal from electrode e134 b is determined; (ii) the base cardiac electrogram signal and thecardiac electrogram signal from electrode e2 34 c is determined; (iii)the base cardiac electrogram signal and the cardiac electrogram signalfrom electrode e3 34 d is determined; (iv) the base cardiac electrogramsignal and the cardiac electrogram signal from electrode e4 34 e isdetermined; (v) the base cardiac electrogram signal and the cardiacelectrogram signal from electrode e5 34 f is determined; (vi) the basecardiac electrogram signal and the cardiac electrogram signal fromelectrode e6 34 g is determined; (vii) the base cardiac electrogramsignal and the cardiac electrogram signal from electrode e7 34 h isdetermined; and (viii) the base cardiac electrogram signal and thecardiac electrogram signal from electrode e8 34 i is determined.

In an exemplary embodiment, the similarities between the electrogramsignals are determined using any method that can measure and establishthe morphological similarities of signals, such as wavelet algorithms,correlation, etc. The determined similarities and/or differences betweenthe electrogram signals are used to map cardiac tissue. Arepresentation, such as a visual depiction, of the determinedsimilarities and/or differences between the electrogram signals isassociated with a location in a two-dimensional (“2D”) orthree-dimensional (“3D”) spatial map of cardiac tissue.

By way of example, if the base cardiac electrogram signal from the baseelectrode e 34 a is compared against each of the electrogram signalsfrom electrode e1 34 b, electrode e2 34 c, electrode e3 34 d, electrodee4 34 e, electrode e5 34 f, electrode e6 34 g, electrode e7 34 h andelectrode e8 34 i (for a total of eight comparisons), a specific area ofcardiac tissue where the base electrode e 34 a is positioned is mappedbased at least in part on the determined similarities.

In an exemplary embodiment, correlation techniques may be used tocompare the electrogram signals and determine the similarities betweenthe electrogram signals. A correlation value between the base cardiacelectrogram signal and each of the electrogram signals from electrode e134 b, electrode e2 34 c, electrode e3 34 d, electrode e4 34 e, electrodee5 34 f, electrode e6 34 g, electrode e7 34 h and electrode e8 34 i maybe determined. As such, for this example, a total of eight correlationvalues are calculated. In order to create a physical correlation map,the average of the correlation values is mapped to the location of thebase electrode 34 a.

The correlation value, e.g., coefficient, at a given point on atwo-dimensional (“2D”) or three-dimensional (“3D”) spatial map may becomputed by the average of the simple Pearson correlations between theunipolar electrogram signal recorded at that point and simultaneouslyrecorded unipolar electrograms at one or more spatially adjacentelectrodes 30. A correlation coefficient may be a single number thatdescribes the degree of relationship between two variables, e.g., twoelectrogram signals. The average correlation coefficient mapped this wayrepresents how electrically similar the mapping location is relative tothe neighboring substrate. An arrhythmogenic substrate is usuallycreated by spatial dissimilarities in electrical properties of tissue,for example, a conduction block which may be functional and/or anatomic.

The Pearson product-moment correlation coefficient (sometimes referredto as the PPMCC or PCC or Pearson's r) is a measure of the correlation(linear dependence) between two variables X and Y, having a valuebetween +1 and −1 inclusive. The Pearson correlation coefficient iswidely used as a measure of the strength of linear dependence betweentwo variables. The Pearson's correlation coefficient between twovariables is defined as the covariance of the two variables divided bythe product of their standard deviations. The definition involves a‘product moment,’ i.e., the mean (the first moment about the origin) ofthe product of the mean-adjusted random variables.

Pearson's correlation coefficient when applied to a sample is referredto as the sample correlation coefficient or the sample Pearsoncorrelation coefficient (“r”). The formula for r is:

$r = \frac{\sum\limits_{i = 1}^{n}{\left( {X_{i} - \overset{\_}{X}} \right)\left( {Y_{i} - \overset{\_}{Y}} \right)}}{\sqrt{\sum\limits_{i = 1}^{n}\left( {X_{i} - \overset{\_}{X}} \right)^{2}}\sqrt{\sum\limits_{i = 1}^{n}\left( {Y_{i} - \overset{\_}{Y}} \right)^{2}}}$

For example, when using the above formula to calculate the correlationcoefficient for the location where base electrode e 34 a is located, Xrepresents a sample value of the base cardiac electrogram signalrecorded at base electrode e 34 a at a time, and Y represents a samplevalue of one of the plurality of cardiac electrogram signals at the sametime. For instance, one of the plurality of electrogram signals may bethe electrogram signal recorded at one of electrode e1 34 b, electrodee2 34 c, electrode e3 34 d, electrode e4 34 e, electrode e5 34 f,electrode e6 34 g, electrode e7 34 h and electrode e8 34 i. The letter‘n’ represents the number of sample values obtained from the basecardiac electrogram signal or one of the plurality of electrogramsignals for a predetermined amount of time (usually equal to onecycle-length of the arrhythmia).

With respect to the value of ‘n’, if the electrogram signals are 1 kHzsignals, and the electrogram signals are recorded for 300 ms, then nwould be 300, i.e., the number of sample values obtained from the basecardiac electrogram signal may be approximately 300 samples, and thenumber of sample values obtained from one of the plurality ofelectrogram signals may also be approximately 300 samples. The number ofsamples obtained may correspond to one arrhythmia cycle at an electrode34.

An equivalent expression gives the correlation coefficient as the meanof the products of the standard scores. The formula for the samplePearson correlation coefficient r, based on a sample of paired data(X_(i), Y_(i)), is shown below:

$r = {\frac{1}{n - 1}{\sum\limits_{i = 1}^{n}{\left( \frac{X_{i} - \overset{\_}{X}}{s_{X}} \right)\left( \frac{Y_{i} - \overset{\_}{Y}}{s_{Y}} \right)}}}$where$\frac{X_{i} - \overset{\_}{X}}{s_{X}},\overset{\_}{X},{{and}\mspace{14mu} s_{X}}$

are the standard score, sample mean of X (i.e., the sample mean of thetotal number of samples), and sample standard deviation, respectively.

The correlation coefficient ranges from −1 to 1. A correlationcoefficient value of 1 implies that a linear equation describes therelationship between X and Y perfectly, with all data points lying on aline where Y increases as X increases, i.e., there is a perfect positivecorrelation between two variables. A correlation coefficient value of −1implies that all data points lie on a line for which Y decreases as Xincreases, i.e., that there is a perfect negative correlation betweentwo variables. A value of 0 implies that there is no linear correlationbetween the variables X and Y. Correlation values are seldom exactly 1,0 or −1, as most of the time the correlation values fall somewhere inbetween 1 and −1. The closer the correlation value approaches zero, thegreater the variation.

The correlation between variables is a measure of how well the variablesare related, such as the linear relationship between two variables. Forexample an exemplary high correlation value may be predefined as 0.9 to1.0; an exemplary medium correlation value may be predefined as 0.76 to0.9; and an exemplary low correlation value may be predefined as anyvalue equal to or below 0.75. A relationship between two variablesexists when changes in one variable tend to be accompanied by consistentand predictable changes in the other variable.

The direction of the relationship is measured by the sign of thecorrelation, whether it is positive (+) or negative (−). A positivecorrelation means that the two variables tend to change in the samedirection, as one increases, the other variable also increases. Anegative correlation means that the two variables tend to change inopposite directions, e.g., as one increases the other variable tends todecrease. The degree of the relationship between the variables, i.e.,the strength or consistency of the relationship, is measured by thenumerical value of the correlation. A value of 1 indicates a perfectrelationship and a value of 0 indicates no relationship. However, in anexemplary embodiment, for the purpose of this invention, similarity maybe determined based on a high positive value of correlation only. Forexample, a high negative correlation value (e.g. −0.8), a low negativecorrelation value (e.g. −0.2), and a low positive correlation value(e.g. 0.2) may be all regarded as indicators of dissimilarity.

A correlation technique may be used to compare and determine thesimilarities between electrogram signals. As such, in an exemplaryembodiment, a plurality of correlation coefficients, wherein each of theplurality of correlation coefficients corresponds to the base cardiacelectrogram signal and a different one of the plurality of cardiacelectrogram signals may be determined. For instance, the followingcorrelation coefficients may be determined: a first correlationcoefficient between the base cardiac electrogram signal from baseelectrode e 34 a and the electrogram signal from electrode e1 34 b; asecond correlation coefficient between the base cardiac electrogramsignal and the electrogram signal from electrode e2 34 c; a thirdcorrelation coefficient between the base cardiac electrogram signal andthe electrogram signal from electrode e3 34 d; a fourth correlationcoefficient between the base cardiac electrogram signal and theelectrogram signal from electrode e4 34 e; a fifth correlationcoefficient between the base cardiac electrogram signal and theelectrogram signal from electrode e5 34 f; a sixth correlationcoefficient between the base cardiac electrogram signal and theelectrogram signal from electrode e6 34 g; a seventh correlationcoefficient between the base cardiac electrogram signal and theelectrogram signal from electrode e7 34 h; and an eighth correlationcoefficient between the base cardiac electrogram signal and theelectrogram signal from electrode e8 34 i.

The plurality of correlation coefficients determined, e.g., the first,second, third, fourth, fifth, sixth, seventh and eighth correlationcoefficients, are averaged. For instance, the first, second, third,fourth, fifth, sixth, seventh and eighth correlation coefficients may be0.8, 0.4, 0.9, 0.7, 0.7, 0.8, 0.9 and 0.8 respectively. In this case,the average of the plurality of correlation coefficients is equal to0.75 (e.g., (0.8+0.4+0.9+0.7+0.7+0.8+0.9+0.8)/8). The average of theplurality of correlation coefficients is associated to the specific areaof cardiac tissue where the base electrode e 34 a is positioned.

As such, the specific area of the cardiac tissue where the basedelectrode e 34 a is positioned is mapped to the average of the pluralityof correlation coefficients, which in this example is the value 0.75. Animage corresponding to a specific area of cardiac tissue, wherein theimage includes a visual representation of the average of the determinedsimilarities between the base cardiac electrogram signal and each of theplurality of cardiac electrogram signals may be displayed on a displaysystem.

The average correlation coefficient can be computed for each electrode34 positioned at a location where mapping is desired. For example, inorder to map a different area of cardiac tissue, such as the neighborarea (neighbor area to the specific area where base electrode e 34 a ispositioned) where neighbor electrode e1 34 b is positioned, adetermination is made as to which electrodes 34 are neighbors toneighbor electrode e1 34 b. In this example, the neighbors of electrodee1 34 b are: base electrode e 34 a, electrode e2 34 c, e4 34 e,electrode 34 r, electrode 34 p, electrode 34 k, electrode 34 l andelectrode 34 m, since these electrodes 34 are located within twomillimeters from electrode e1 34 b.

A neighbor cardiac electrogram signal at electrode e1 34 b is recorded.Additionally, electrogram signals at the electrodes that are neighborsto e1 34 b are also recorded (e.g., base electrode e 34 a, electrode e234 c, e4 34 e, electrode 34 r, electrode 34 p, electrode 34 k, electrode34 l and electrode 34 m). The neighbor cardiac electrogram signalrecorded at electrode e1 34 b (which is a neighbor of electrode e 34 a)is compared to each of the electrogram signals recorded at baseelectrode e 34 a, electrode e2 34 c, e4 34 e, electrode 34 r, electrode34 p, electrode 34 k, electrode 34 l and electrode 34 m.

For example, the neighbor cardiac electrogram signal recorded atelectrode e1 34 b is compared to the base cardiac electrogram signalrecorded at base electrode e 34 a; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode e2 34 c; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode e4 34 e; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode 34 r; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode 34 p; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode 34 k; the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode 34 l; and the neighbor cardiac electrogramsignal recorded at electrode e1 34 b is compared to the electrogramsignal recorded at electrode 34 m.

The similarities between the neighbor cardiac electrogram signal fromneighbor electrode e1 34 b and each of the electrogram signals recordedat base electrode e 34 a, electrode e2 34 c, e4 34 e, electrode 34 r,electrode 34 p, electrode 34 k, electrode 34 l and electrode 34 m aredetermined. Correlation coefficients may be used to determine thesimilarities between: (i) the neighbor electrogram signal from neighborelectrode e1 34 b and the base cardiac electrogram signal from electrodee 34 a; and (ii) the neighbor cardiac electrogram signal from neighborelectrode e1 34 b and each of the plurality of cardiac electrogramsignals other than the neighbor cardiac electrogram signal (e.g. theelectrogram signals recorded at electrode e2 34 c, e4 34 e, electrode 34r, electrode 34 p, electrode 34 k, electrode 34 l and electrode 34 m).

In an exemplary embodiment, to determine the similarities between theneighbor cardiac electrogram signal and the plurality of electrogramsignals, a plurality of neighbor correlation coefficients aredetermined, wherein each of the plurality of neighbor correlationcoefficients corresponds to the neighbor electrogram signal fromneighbor electrode e1 34 b and one of (i) a different one of theplurality of cardiac electrogram signals from electrode e2 34 c, e4 34e, electrode 34 r, electrode 34 p, electrode 34 k, electrode 34 l andelectrode 34 m; and (ii) the base cardiac electrogram signal.

For example, the following neighbor correlation coefficients can bedetermined: a ninth correlation coefficient between the electrogramsignal from neighbor electrode e1 34 b and the base electrogram signalfrom electrode e 34 a; a tenth correlation coefficient between theelectrogram signal from neighbor electrode e1 34 b and the electrogramsignal from electrode e2 34 c; an eleventh correlation coefficientbetween the electrogram signal from neighbor electrode e1 34 b and theelectrogram signal from electrode e4 34 e; a twelfth correlationcoefficient between the electrogram signal from neighbor electrode e1 34b and the electrogram signal from electrode 34 r; a thirteenthcorrelation coefficient between the electrogram signal from neighborelectrode e1 34 b and the electrogram signal from electrode 34 p; afourteenth correlation coefficient between the electrogram signal fromneighbor electrode e1 34 b and the electrogram signal from electrode 34k; a fifteenth correlation coefficient between the electrogram signalfrom neighbor electrode e1 34 b and the electrogram signal fromelectrode 34 l; and a sixteenth correlation coefficient between theelectrogram signal from neighbor electrode e1 34 b and the electrogramsignal from electrode 34 m.

The plurality of neighbor correlation coefficients (e.g., the ninth, thetenth, the eleventh, the twelfth, the thirteenth, the fourteenth, thefifteenth and the sixteenth correlation coefficients) are averaged, andthe average of the plurality of neighbor correlation coefficients isassociated to the neighbor area of cardiac tissue where the neighborelectrode 1 b 34 b is positioned. For example, if the average of thecorrelation coefficient is 0.8, the location where electrode e1 34 b ispositioned will be mapped to the value of 0.8. The method is repeatedfor each electrode 34, until a correlation map 64 showing a visualdepiction of the average correlation coefficient for each location whereelectrodes 34 of interest are positioned is created.

Referring now to FIG. 7, an exemplary spatial 2D correlation map 64 ofcardiac tissue is shown. The correlation map 64 can be generated usingcorrelation coefficients associated with simultaneous electrogramsignals obtained at neighboring unipolar electrodes 34 for a givenarrhythmia cycle. The color key 66 includes an exemplary range ofaverage correlation coefficient values that may be associated with anarea where an electrode 34 is positioned, and associates the averagecorrelation coefficient values with a color. In this way, the averagecorrelation coefficient value imputed to an area may be visuallyrepresented by a color in the correlation map 64.

In an exemplary embodiment, the cardiac tissue mapped may includedifferent areas, such as area I 68, area II, area III 70, area IV 72 andarea V 74. The exemplary correlation map 64 uses grayscale to indicatethe different values of the average correlation coefficients associatedto each area. For example, since area V 74 is associated with an averagecorrelation coefficient that is low, e.g., less than 0.5, area V 74 maybe visually depicted on the correlation map 64 as an area having thedarkest shade. Area IV 72 is associated with an average correlationcoefficient that is 0.5 or more but less than 0.6 and may be visuallydepicted on the correlation map 64 as an area with a shade that is lessdark than the shade of area V 74. Area III 70 is associated with anaverage correlation coefficient that is 0.6 or more, but less than 0.7,and may be visually represented on the correlation map 64 as an areahaving a light shade. Area II may be associated with an averagecorrelation coefficient that is 0.7 or more, but less than 0.8, and maybe visually represented on the correlation map 64 as an area having alighter shade than area III 70. Area I 68 is associated with a highaverage correlation coefficient that is 0.8 or more and may berepresented as the area having the lightest shade.

Since area V 74 has the darkest shading, this indicates that the averagecorrelation coefficients corresponding to the electrogram signalsrecorded at electrodes 34 positioned in area V 74 have a value below0.5. The low correlation coefficient may suggest that area V 74 includesdamaged or arrhythmogenic cardiac tissue. The determination as towhether a specific area of cardiac tissue is damaged or arrhythmogenicor not depends on whether or not the electro gram signal recorded atthat specific area of cardiac tissue is similar to the electro gramsignals recorded at neighboring electrodes 34. If the electrogram signalrecorded at that specific area of cardiac tissue is similar to theelectrogram signals recorded at neighboring electrodes 34, then thespecific area will probably not include damaged or arrhythmogeniccardiactissue, as the high degree of similarity between the electrogram signalsis indicated by a high correlation between the electrogram signals.However, if the electrogram signal recorded at that specific area ofcardiac tissue is not similar to the electrogram signals recorded atneighboring electrodes 34, then the specific area would probably includedamaged or arrhythmogenic cardiac tissue, i.e., there is a lowcorrelation between the electrogram signals.

In this exemplary embodiment, the comparison of the base cardiacelectrogram signal recorded at base electrode e 34 a in area V 74 to theelectrogram signals recorded at electrodes 34 that are neighbors to baseelectrode e 34 a, revealed that the correlation between the base cardiacelectrogram signal and the plurality of neighboring electrogram signalsis low. The electrogram signals were compared using Pearson correlationcoefficients. The correlation computations resulted in Pearsoncorrelation coefficients with an average value below 0.5, such as forexample 0.45. The average correlation coefficient is mapped to thelocation where base electrode e 34 a is positioned in area V 74, i.e.,area V 74 is associated with a visual representation of an averagecorrelation coefficient having a value below 0.5. As such, mapping isachieved by associating the value of an average correlation coefficientto an area in the correlation map 64 corresponding to cardiac tissuewhere an electrode 34 is positioned.

In an exemplary embodiment, a determination may be made as to whetherthe mapping value of the area V 74 is similar to the mapping value ofthe neighbor area I 68. For instance, a determination may be made as towhether a correlation coefficient associated with area V 74 is similarto a correlation coefficient associated with area I 68. If it isdetermined that the mapping value of the area V 74 of cardiac tissue issimilar to the mapping value of the neighbor area I 68, then it may belikely that neither area V 74 or the neighbor area I 68 include damagedor arrhythmogenic cardiac tissue. Else, if it is determined that themapping value of the area V 74 of cardiac tissue is not similar to themapping value of the neighbor area I 68, then it may be determined thatone of area V 74 and the neighbor area I 68 includes damaged orarrythmogenic cardiac tissue.

Different colors may be used for different areas of correlation map 64to indicate the value of the average correlation coefficient in eacharea. For example, in one embodiment, area V having a low averagecorrelation coefficient, such as a correlation coefficient having avalue below 0.5, may be visually represented as a red area. Area IVassociated with an average correlation coefficient having a value of 0.5or more, but less than 0.6 may be visually represented in thecorrelation map 64 as a yellow area. Area III associated with an averagecorrelation coefficient with a value of 0.6 or more, but less than 0.7may be visually depicted in the correlation map 64 as a light greenarea. Area II associated with an average correlation coefficient havinga value of 0.7 or more, but less than 0.8 may be visually represented inthe correlation map 64 as a darker green area. Area I having an averagecorrelation coefficient that has a value of 0.8 or above may be visuallyrepresented in the correlation map 64 as a blue area.

Simultaneous cardiac substrate mapping includes the recording of aplurality of neighboring electrogram signals at substantially the sametime, i.e., the same epoch. Since the electrogram signals are recordedat different electrodes 34 for the same arrhythmia cycle, i.e., the sameepoch, there may be no need to align the electrogram signals in order toproperly compare the electrogram signals. Data obtained over multipleepochs may be used to create the correlation map 64 in order to ensureconsistency in areas of discontinuous conduction (e.g., rotor) overdifferent epochs and as a measure of stability of the arrhythmia cycle.

It is common to compare electrogram signals recorded at different timesby aligning them with each other. During alignment, an electrogramsignal taken at a time is aligned with another electrogram signal takenat a different time. For instance, the peaks, e.g., the maximum valuesof an electrogram signal, may be aligned with the peaks of anotherelectrogram signal. Alignment is difficult for complex electrogramsignals, as these signals may have multiple deflections and peaks,making it challenging to ascertain which peaks of an electrogram signalshould be aligned with which peaks of another electrogram signal. Thiscomplexity may result in the alignment process aligning peaks and phaseswhich do not correspond to each other. In an exemplary embodiment, themethods described herein may not need alignment of the electrogramsignals, given that the electrogram signals from multiple electrodes 34are obtained simultaneously, at the same time or at substantially thesame time.

FIG. 8 shows an exemplary canine infarct model correlation map 76 andcolor key 78. The correlation map 76 may be created employing themethods described herein for simultaneous cardiac substrate mappingusing spatial correlation maps between electrograms from neighboringunipolar electrodes. The electrogram signals utilized to createexemplary correlation map 76 may be recorded using electrodes 34positioned directly on the epicardial layer of a ventricle. Thecorrelation map 76 may allow the visual identification of abnormalcardiac substrate, e.g., areas where a possible rotor may be located.Specifically, areas of high correlation adjacent to areas of lowcorrelation may indicate that areas having a low correlation valueinclude abnormal cardiac substrate. Ablation therapy may be targeted atsuch areas of low correlation including the boundary between spatiallyadjacent areas of low and high correlation, e.g., the border zone of aninfarct which is a common target for therapeutic ablation of myocardialinfarction patients with re-entrant ventricular arrhythmias. A visualrepresentation of correlation map 76 may be displayed on display 60.

The boundary between an area of high correlation and an area of lowcorrelation delineates the border-zone of the infarct, separating theinfarct from the healthy tissue. During a re-entrant arrhythmia, suchinfarcts usually include a rotor around the re-entry point. The rotor isidentified by determining the area/region which is electrically mostincongruous with the rest of the other areas. The rotor-boundary mayeither form an anatomic block or a functional block. In complexarrhythmias, like an AF, the rotor may also precess or form a trajectoryof its own over different cycles.

As such, an area of cardiac tissue associated with an averagecorrelation coefficient having a low value may indicate that a rotor ora myocardial scar exists in that low correlation area. Specifically, theboundary between regions of high correlation and low correlation may beindicative of abnormal substrate. Abnormal substrate may be a potentialtarget for ablation, as ablation disrupts the abnormal conduction paths,which may prevent re-entrant arrhythmias.

Exemplary correlation map 76 shows a couple of areas of interest.Correlation map 76 shows exemplary area I 80, area II 82, area III 84,area IV 86, area V 88, area VI 90, area VII 92, area VIII 94, area IX96, area XI 97, selected area 98, area XII 99, selected area 100, areaXIV 101, area X 102 and area XIII 103. In the exemplary correlation map76, the average correlation coefficient associated with area I 80 has avalue of 0.95 or above. The average correlation coefficient associatedwith area II 82 has a value of 0.9 or above, but below 0.95. The averagecorrelation coefficient associated with area III 84 and area IV 86 has avalue of 0.85 or above, but below 0.9. The average correlationcoefficient associated with area V 88 has a value of 0.8 or above, butbelow 0.85. The average correlation coefficient associated with area VI90 has a value of 0.75 or above, but below 0.8. The average correlationcoefficient associated with area VII 92 has a value of 0.7 or above, butbelow 0.75. The average correlation coefficient associated with areaVIII 94 and area IX 96 has a value that is below 0.7.

The average correlation coefficient associated with area XI 97 has avalue of 0.7 or above, but below 0.75. The average correlationcoefficient associated with area XII 99 has a value of 0.8 or above, butbelow 0.85. The average correlation coefficient associated with area XIV101 has a value of 0.75 or above, but below 0.8. The average correlationcoefficient associated with area XIII 103 has a value of 0.7 or above,but below 0.75.

As such, correlation map 76 indicates that area I 80, area II 82, areaIII 84, area IV 86 and area V 88 are areas of healthy cardiac tissue, asthe electrogram signals from these areas are highly correlated with theelectrogram signals from neighboring areas. Correlation map 76 alsoindicates that areas VI 90, area VII 92, area VIII 94, area XIII 103,area XI 97 and area IX 96 are areas of low correlation, i.e., theelectrogram signals from these areas and the electrogram signals fromneighboring areas have a low correlation. Specially, correlation map 76indicates that area VII 92, area VIII 94, area IX 96, area XI 97, andarea XIII 103 are the areas that have the lowest correlation. Theelectrogram signals recorded at these areas of low correlation arepoorly correlated with the electrogram signals recorded at areas of highcorrelation.

Since the areas of low correlation may be indicative of abnormalsubstrate, these areas may be selected for ablation. A border around theareas of low correlation may be drawn to delineate selected area A 98and selected area 100. Selected area A 98 includes area IX 96, which hasa low correlation coefficient with a value below 0.7, area XI 97, whichhas a low correlation coefficient with a value of 0.7 or above, butbelow 0.75, and area XII 99, which has a correlation coefficient with avalue of 0.8 or above, but less than 0.85.

Selected area B 100 includes area 90 VI, which has a correlation valueof 0.75 or above, but below 0.8; area VII 92 which has a correlationvalue of 0.7 or above but less than 0.75; area VIII 94, which has acorrelation value below 0.7, area XIV 101 which has a correlationcoefficient value of 0.75 or above, but below 0.8, and area XIII 103,which has a correlation coefficient value of 0.7 or above, but below0.75.

The boundaries of selected area A 98 and selected area B 100 may, forexample, identify a myocardial scar boundary. As such, selected area A98 and area B 100 may be selected for ablation. The cardiac tissueinside the borders of selected area A 98 and selected area B 100 may beablated. If so, area X 102 will be an island of surviving cardiac tissueafter the ablation of selected area A 98 and selected area B 100.

In another exemplary embodiment, the boundaries of the areas can bedefined according to a particular specified gradient. For example, ifthe difference in the correlation value is 0.2, then the mapping may beconfigured to visually depict this difference. The size of an areaselected for ablation may be customized depending on the differences ofthe correlation value associated with the area and the correlationvalues associated with neighboring areas.

FIG. 9 illustrates the graphs of three different electrogram signals104, 106 and 108. The graphs illustrate how the voltage of theelectrogram signals 104, 106 and 108 changes as a function of time(milliseconds). Electrogram signal 104 and electrogram signal 106 arehighly correlated, i.e., changes in the voltage (millivolts) ofelectrogram signal 104 as a function of time mimic the changes involtage of electrogram signal 106 as a function of time. Electrogramsignal 104 and electrogram signal 106 may correspond to, for example,area III 84 and area IV 86 of FIG. 8 respectively. Electrogram signals104 and 106 may correspond to two neighboring electrodes 34, such aselectrode e3 34 d and electrode e5 34 f.

Electrogram signal 108 may correspond to, for example, electrode 34 apositioned in a border zone area neighboring the two electrodes 34(e.g., electrode e3 34 d and electrode e5 34 f), such as area VII 92(shown in FIG. 8). The electrogram signal 108 is poorly correlated withboth electrogram signals 104 and 106. The low correlation may indicatethat area VII 92 may include abnormal cardiac substrate, which may bethe target of ablation for, for example, re-entrant arrhythmias.

FIG. 10 shows another exemplary correlation map 110 and a color key 112.Exemplary correlation map 110 was produced using correlationcoefficients having values that range from positive to negative. Forexample, area I 114 has a low average correlation coefficient that isbelow −0.8. The rest of the areas in correlation map 110, e.g., area II116, area III 118, area IV 120, area V 122 and area V 124, have anaverage correlation coefficient above 0.6. Exemplary correlation map 110may indicate that area I 114 is a possible candidate for ablation, as itmay include a myocardial scar, a discontinuation in conduction, etc.

Of note, while the disclosure refers to cardiac tissue, the invention isnot limited to such, as any type of tissue may be mapped using themethods described herein. Further, while the disclosure refers tocorrelation as an exemplary method of comparing electrogram signals, anymethod of comparing signals may be used. Further, the methods describedmay be applied epicardially, endocardially or in any area of the body.

Referring now to FIG. 11, a flow chart illustrating the various steps ofan exemplary method for mapping cardiac tissue is depicted. The methodincludes providing the medical device 12 having the plurality ofelectrodes 34 coupled to the distal portion 20. The plurality ofelectrodes 34 may be positioned proximate and/or in direct contact witha tissue region to be examined, for example, the myocardium or anycardiac tissue. When positioned proximate or in contact with the targettissue region, radiofrequency energy may be transmitted between theplurality of electrodes 34 and/or from at least one of the plurality ofelectrodes 34 to the reference electrode.

In step 126, a base cardiac electrogram signal may be recorded at a baseelectrode (Step 126). The base cardiac electrogram signal may berecorded for a predetermined length of time. In one exemplaryembodiment, the signal recorded may be an electrocardiogram signal (ECG)recorded proximate the myocardium. The recorded signal may be in vivo ormay be a previously recorded signal.

In step 128, a plurality of cardiac electrogram signals at a pluralityof electrodes other than the base electrode are recorded for thepredetermined amount of time (Step 128). The base cardiac electrogramsignal is compared to each of the plurality of cardiac electrogramsignals in order to determine how the base cardiac electrogram signal issimilar or different to each of the other cardiac electrogram signals(Step 130). The similarities or differences between the base cardiacelectrogram signal and each of the plurality of cardiac electrogramsignals is determined (Step 132). A specific area of cardiac tissuewhere the base electrode is positioned is mapped based at least in parton the determined similarities or differences (Step 134).

It will be appreciated by persons skilled in the art that the presentinvention is not limited to what has been particularly shown anddescribed herein above. In addition, unless mention was made above tothe contrary, it should be noted that all of the accompanying drawingsare not to scale. A variety of modifications and variations are possiblein light of the above teachings without departing from the scope andspirit of the invention, which is limited only by the following claims.

What is claimed is:
 1. A method of treating arrhythmogenic cardiac tissue, comprising: recording a base cardiac electrogram signal at a base electrode for a predetermined amount of time; recording a plurality of cardiac electrogram signals at a plurality of electrodes other than the base electrode for the predetermined amount of time; comparing the base cardiac electrogram signal with each of the plurality of cardiac electrogram signals; determining an average correlation coefficient associated with the base cardiac electrogram signal and each of the plurality of cardiac electrogram signals; mapping a specific area of cardiac tissue where the base electrode is positioned based at least in part on the determined average correlation coefficient; analyzing the average correlation coefficient to determine whether the average correlation coefficient has a low value; identifying the specific area of cardiac tissue as arrhythmogenic cardiac tissue when the average correlation coefficient has a low value; providing a medical device including an ablation element; identifying a closed boundary between the arrhythmogenic cardiac tissue and surrounding cardiac tissue based at least in part on the average correlation coefficient; placing the medical device in contact with the arrhythmogenic cardiac tissue; and activating the ablation element and ablating substantially all of the arrhythmogenic cardiac tissue within the boundary.
 2. The method of claim 1, wherein the average correlation coefficient is determined using a plurality of correlation coefficients.
 3. The method of claim 2, wherein each of the plurality of correlation coefficients is a Pearson correlation coefficient, and wherein each of the plurality of correlation coefficients is computed using the formula: $r = \frac{\sum\limits_{i = 1}^{n}{\left( {X_{i} - \overset{\_}{X}} \right)\left( {Y_{i} - \overset{\_}{Y}} \right)}}{\sqrt{\sum\limits_{i = 1}^{n}\left( {X_{i} - \overset{\_}{X}} \right)^{2}}\sqrt{\sum\limits_{i = 1}^{n}\left( {Y_{i} - \overset{\_}{Y}} \right)^{2}}}$ wherein X represents a sample value of the base cardiac electrogram signal at a time, Y represents a sample value of one of the plurality of cardiac electrogram signals at the time, and n is a number of sample values obtained from the base cardiac electrogram signal.
 4. The method of claim 1, wherein the base electrode is included on the medical device, the method further comprising providing a reference electrode a distance from the medical device and transmitting energy from the base electrode to the reference electrode.
 5. The method of claim 1, further comprising displaying an image corresponding to the specific area of cardiac tissue, wherein the image includes a visual representation of an average of the determined similarities between the base cardiac electrogram signal and each of the plurality of cardiac electrogram signals.
 6. The method of claim 1, wherein the recording of the base cardiac electrogram signal and the recording of the plurality of cardiac electrogram signals occur substantially simultaneously.
 7. The method of claim 1, wherein the predetermined distance is between one millimeter and twenty millimeters.
 8. The method of claim 1, further comprising: measuring a cycle length of an arrhythmia in a patient having atrial fibrillation, the predetermined amount of time being substantially equal to the cycle length of the arrhythmia.
 9. A medical system, comprising: a medical device including a base electrode and a plurality of electrodes; and a control unit in communication with the base electrode and the plurality of electrodes, the control unit operable to: record a base cardiac electrogram signal at a base electrode for a predetermined amount of time; record a plurality of cardiac electrogram signals at a plurality of electrodes other than the base electrode for the predetermined amount of time; compare the base cardiac electrogram signal with each of the plurality of cardiac electrogram signals; determine an average correlation coefficient associated with the base cardiac electrogram signal and each of the plurality of cardiac electrogram signals; map a specific area of cardiac tissue where the base electrode is positioned based at least in part on the determined average correlation coefficient; analyze the average correlation coefficient to determine whether the average correlation coefficient has a low value; identify the specific area of cardiac tissue as arrhythmogenic cardiac tissue when the average correlation coefficient has a low value; identify a closed boundary between the arrhythmogenic cardiac tissue and surrounding cardiac tissue based at least in part on the average correlation coefficient; place the medical device in contact with the arrhythmogenic cardiac tissue; and activate the plurality of electrodes and ablating substantially all of the arrhythmogenic cardiac tissue within the boundary.
 10. The medical system of claim 9, further comprising a display, the control unit being further operable to display an image corresponding to the specific area of cardiac tissue on the display, wherein the image includes a visual representation of an average of the determined average correlation coefficients between the base cardiac electrogram signal and each of the plurality of cardiac electrogram signals.
 11. The medical system of claim 9, wherein the control unit is further operable to: determine whether the mapping of the specific area of cardiac tissue is similar to a mapping of a neighbor area of cardiac tissue; and if it is determined that the mapping of the specific area of cardiac tissue is not similar to the mapping of the neighbor area of cardiac tissue, then determining that one of the specific area of cardiac tissue and the neighbor area of cardiac tissue includes one of damaged and arrhythmogenic cardiac tissue.
 12. The medical system of claim 9, wherein each of the plurality of electrodes has a neighbor electrode positioned at a neighbor area of cardiac tissue, the control unit being further operable to: record a neighbor cardiac electrogram signal at the neighbor electrode for the predetermined amount of time; compare the neighbor cardiac electrogram signal with the base cardiac electrogram signal; compare the neighbor cardiac electrogram signal with each of the plurality of cardiac electrogram signals other than the neighbor cardiac electrogram signal; determine similarities between: the neighbor cardiac electrogram signal and the base cardiac electrogram signal; and the neighbor cardiac electrogram signal and each of the plurality of cardiac electrogram signals other than the neighbor cardiac electrogram signal; and map the neighbor area of cardiac tissue based at least in part on the determined similarities.
 13. The medical system of claim 12, wherein the control unit is further operable to: determine a plurality of neighbor correlation coefficients, wherein each of the plurality of neighbor correlation coefficients corresponds to the neighbor electrogram signal and one of a different one of the plurality of cardiac electrogram signals and the base cardiac electrogram signal; average the plurality of neighbor correlation coefficients; and associate an average of the plurality of neighbor correlation coefficients to the neighbor area of cardiac tissue where the neighbor electrode is positioned.
 14. The medical system of claim 13, further comprising a display, the control unit being further operable to: display an image on the display, the image being associated with the specific area of cardiac tissue and the neighbor area of cardiac tissue, wherein the image includes a visual representation of: an average of the plurality of correlation coefficients; and an average of the plurality of neighbor correlation coefficients.
 15. The medical system of claim 13, wherein the control unit is further operable to: determine whether the average of the plurality of correlation coefficients is different than the average of the plurality of neighbor correlation coefficients; and if it is determined that the average of the plurality of correlation coefficients is different than the average of the plurality of neighbor correlation coefficients, then determining that one of the specific area of cardiac tissue and the neighbor area of cardiac tissue includes one of damaged and arrhythmogenic cardiac tissue. 